Perception, typology, consequences and perpetrators of mistreatment in medical students: a cross-sectional study in Ecuador 2024

Abstract

Background

Mistreatment of medical students represents a widely documented structural problem in medical training institutions worldwide. Its high prevalence, adverse effects in mental health and academic performance, as well as low reporting rates, highlight the urgent need to characterize this phenomenon in local contexts. In Ecuador, there are few studies that address this issue from an empirical perspective.

Objective

To analyze the perception, types, perpetrators, effects and reporting of mistreatment among medical students at a public Ecuadorian university, differentiating findings by training cycle (basic vs clinical) and gender.

Material and methods

A descriptive cross-sectional study was conducted with a random sample of 556 students. An online questionnaire was administered, adapted from a previously validated instrument (Cronbach’s α = 0.96) structured into five sections: sociodemographic data, perception of mistreatment, involved perpetrators, perceived effects and reporting. Descriptive and inferential statistics (Chi-square and Fisher’s exact tests) were performed using R software. The study protocol was approved by an institutional ethics committee.

Results

Overall, 96.2% of participants reported experiencing at least one episode of mistreatment, yet only 72.5% explicitly recognized it as such. Prevalence was higher in the clinical training phase. Psychological mistreatment was the most frequent type, followed by academic, physical and sexual. Faculty physicians were identified as the main perpetrators 87.9%. Over 90% reported negative effects, primarily personal, with higher effects in the clinical cycle students. Female students had lower risk of physical mistreatment (OR: 0.60; IC 95%: 0.36–0.99) but higher risk of sexual mistreatment (OR: 1.77; 95% CI: 1.23–2.55). Non-reporting rates were 90.6%, primarily due to fear of retaliation and perception of institutional ineffectiveness.

Conclusions

Mistreatment in medical education is highly prevalent, particularly during clinical training, with significant personal, academic, and social consequences. The lack of recognition and low reporting rates reflect an institutional culture that normalizes these behaviors. There is an urgent need to implement support strategies of prevention, detection and attention of mistreatment focused on gender with safe and effective reporting mechanisms.

Introduction

Over the years, mistreatment has been used as a pedagogical strategy across various disciplines, particularly within the health sciences field [1]. In Latin America, numerous studies have reported that over 50% of medical students have experienced some form of mistreatment throughout their academic training, with prevalence rates varying depending on the year of study, with certain contexts reporting figures exceeding 90% [2, 3]. These behaviors are primarily manifested in two forms, based on the hierarchical position of those involved: vertical or horizontal mistreatment. In the medical field, vertical mistreatment, perpetrated by authority figures, is the predominant pattern [4].

The perception of mistreatment among medical students varies depending on the stage of their education and the environment in which it occurs. In the early years of the medical curriculum, within the classroom setting, mistreatment is often associated with foundational theoretical instruction, whereas, in the later years, during clinical rotations in hospital settings, mistreatment is linked to clinical training process and healthcare environment [5]. The primary perpetrators include attending physicians, faculty members, peers, and residents. Furthermore, within the clinical setting, episodes of mistreatment have also been reported by nursing staff and even by administrative staff within healthcare and academic institutions [6].

The impact of mistreatment on medical students affects multiple dimensions of their personal, academic, professional, and social well-being. Among the most frequently observed consequences are heightened levels of stress, anxiety, and emotional distress, diminished self-efficacy regarding clinical competence, and a significant decline in motivation toward academic pursuits. Additionally, there is often a deterioration in the quality of familial and social relationships, as well as a negative impact on academic performance and future professional development [5].

Despite the high global prevalence rates reported, most instances of mistreatment among medical students remain unreported to the relevant institutional authorities. This underreporting is primarily attributed to fear of retaliation and a lack of confidence in the efficacy of institutional mechanisms designed to address and solve such cases [7].

In Ecuador, there are 21 accredited higher education institutions offering medical programs [8]. Although there exist several studies that analyzed this issue, to date, no studies have been identified to compare mistreatment across different stages of student training (basic or clinical education) as well as its psychological effects, within the context of a public university. Therefore, the aim of this study was to analyze the perception and typology of mistreatment in medical students at a public Ecuadorian university during the 2024–2024 period, as well as the actors involved, and to explore the potential differentiated effects according to the stage of training, whether basic or clinical.

Materials and methods

Study design

A descriptive cross-sectional study was conducted during the period of November–December 2024 to assess the perception, typology, actors, and effects of mistreatment across different stages of student training basic or clinical.

Context and setting

The study was conducted in medical students at an Ecuadorian public university offering a medical degree program, accredited at national level. The training is divided into two stages: basic sciences (first to fifth semester) and clinical sciences (sixth to eleventh semester), encompassing theoretical training, practical sessions, and hospital rotations.

Participants and sample size

The target population comprised 2709 students enrolled in the medical program. Of these, 1328 belonged to the basic sciences cycle, and 1381 to the clinical sciences cycle. The sample size was calculated using a 95% confidence interval, a 5% margin of error, and an estimated prevalence of 50%, yielding a minimum required sample size of 482 students. To account for potential attrition and non-response bias, the sample size was expanded to 530 participants.

Inclusion criteria

There were included students enrolled and students regularly attending classes during the study period, who accepted to take part through voluntary informed consent and fully completed the web-based questionnaire. We excluded students who either declined to provide voluntary informed consent or were enrolled in academic exchange programs.

Variables

The variables analyzed in this study included sociodemographic characteristics, such as: age in years, sex, marital status and ethnic self-identification; academic variables as: current semester and enrollment type (first-time, repeating, or re-entry) and variables of perception and experience of mistreatment, among this: prevalence and type of suffered mistreatment, perpetrators, perceived personal, academic, social impacts potentially attributable to mistreatment. In addition, the reporting of abuse episodes was investigated, considering both the actions taken by students after experiencing such situations and the reasons for not reporting.

Instrumentation and data collection

Data were collected using a self-administered online questionnaire through the open-source platform KoBoCollect, designed from adaptation of a validated tool developed by Munayco-Guillén et al. with a Cronbach's alpha of 0.8 [2]. In addition, Barbanti et al.’s systematic review was considered, which addresses medical student mistreatment effects [9].

The adapted questionnaire included sections for collecting general data, perception, and frequency of mistreatment experiences, identification of perpetrators, perceived personal, academic, and social effects, as well as actions taken or the absence of reporting episodes. Except for the general data section, the remaining sections were structured with Likert-type questions offering frequency options ranging from never, a few times, sometimes, several times, and always. At the end there was a self-identification question. The adapted questionnaire underwent internal consistency analysis in 40 participants of another public university of Ecuador, yielding a Cronbach's Alpha of 0.96, reflecting high reliability of the instrument.

To ensure the minimum sample size, the survey was disseminated through official media each semester. Students' courses were also visited to disseminate the survey online.

Bias mitigation

To minimize selection bias, stratified random sampling by training cycle (basic sciences vs. clinical sciences) was employed. Additionally, anonymity of participants was guaranteed to reduce social desirability bias.

Statistical analysis

Collected data were stored in Excel and analyzed using software R version 4.3. Categorical variables were presented as absolute (n) and relative frequencies (%). Age, as a discrete quantitative variable, was described using median and interquartile range (IQR), after confirming non-normal distribution via Kolmogorov–Smirnov test.

For inferential analysis, mistreatment perception (psychological, physical, academic, and sexual) was compared between basic and clinical sciences students. Participants were classified as reporting “No” mistreatment if they responded “Never” to all items in each corresponding section. Group comparisons were performed using Chi-square and Fisher's exact tests, as appropriate. Associations between sociodemographic variables and different mistreatment types were quantified using logistic regression expressed as adjusted odds ratios (AOR).

Ethical considerations

The study protocol was reviewed and approved by the Research Ethics Committee on Human Subjects at Hospital General San Francisco de Quito (CEISH-HGSF); Approval Code: HREC-HGSF-2024–019. All participants provided digital informed consent before questionnaire access, ensuring adherence to Helsinki Declaration principles (autonomy, justice, beneficence) and current national regulations.

Results

A total of 556 participants were included, of which 50.4% (n = 280/556) were in basic sciences (first to fifth semesters), meanwhile 49.6% (n = 276/556) were in clinical sciences (sixth semester to rotatory internship). Sociodemographic characteristics of the sample studied are presented in Table 1. Most participants were female (67.4%), single, aged between 20 and 24 years, and mostly Mestizos as ethnic self-identification (90.3%). Significant differences were observed: a higher percentage of female students were in basic sciences, while clinical science groups showed a higher proportion of Mestizos and first-time enrollment were more frequent in clinical sciences. (p < 0.05).

Table 1. Sociodemographic characteristics of participants and differences by study cycle

Variables	Total	Study cycle
		Basic sciences	Clinical sciences
	n = 556 (%)	n = 280 (%)	n = 276 (%)	P value
Gender
Female	360 (64.7)	197 (70.4)	163 (59.1)	0.000
Male	196 (35.3)	83 (29.6)	113 (40.9)
Age
X̅; SD	22.1 (2.58)	20.3(1.61)	23.7(2.2)	0.000
x͂; IQR	22(20–24)	20(19–21)	22(23–25)
Marital status
Single	543 (97.7)	276 (98.6)	267 (96.7)	0.152
Other	13 (2.3)	4 (1.4)	9 (3.3)
Ethnic self-identification
Mestizo	502 (90.3)	239 (85.4)	263 (95.3)	0.000
Other	54 (9.7)	41 (14.6)	13 (4.7)
Enrollment
First time	498 (89.6)	231 (82.5)	267 (96.7)	0.000
Re-enrollment	58 (10.4)	49 (17.5)	9 (3.3)
Mistreatment perception
Si	535 (96.2)	263 (93.9)	272 (98.6)	0.003
No	21 (3.8)	17 (6.1)	4 (1.4)
Mistreatment identification
Si	403 (72.5)	176 (62.9)	227 (82.2)	0.000
No	153 (27.5)	104 (37.1)	49 (17.8)

X̅ mean, SD standard deviation, x͂ median, IQR interquartile range

Overall, 96.2% (n = 535/556) of participants reported experiencing at least one mistreatment incident during their training, yet only 72.5% (n = 403/556) reported actually considering themselves victims of mistreatment. Both perception and identification of mistreatment were significantly higher among clinical sciences students (p < 0.05) (Table 1).

According to types of mistreatments, the most reported mistreatment form was psychological, remarking negative comments in 85.4% (n = 475/556) of respondents. Within the physical component, the most frequent type of mistreatment was the assignment of excessive tasks, with a prevalence of 79.0% (n = 439/556). Regarding the academic component 67.4% (n = 375/556) reported having experienced unfair competition and within the sexual component, 35.8% (n = 199/556) reported experiencing verbal innuendos of sexual content or obscene comments (Table 2).

Table 2. Differences in mistreatment perception by study cycle among medical students at a public Ecuadorian university

Types of mistreatments	Frequency			Study cycle
	Never	Frequent	Recurrent	Basic sciences	Clinical sciences
	(0 times)	(1–5 times)	(≥ 6 times)	n = 280 (%)	n = 276 (%)	p*
Psychological Component	36 (6.5)	503 (90.5)	17 (3.0)	250(89.3)	270(97.8)	0.000
I have been yelled at	102 (18.3)	337 (60.7)	117 (21.0)	238 (85.0)	263 (95.3)	0.000
I have received negative or derogatory comments	81 (14.6)	318 (57.2)	157 (28.2)	219 (78.2)	256 (92.8)	0.000
I have been humiliated	136 (24.5)	308 (55.4)	112 (20.1)	188 (67.1)	232 (84.1)	0.000
I have been insulted	267 (48.1)	226 (40.6)	63 (11.3)	112 (40.0)	177 (64.1)	0.000
I have received unjustified criticism	125 (22.5)	305 (54.9)	126 (22.6)	183 (65.4)	248 (89.9)	0.000
I have been mocked because of my gender	427 (76.8)	99 (17.8)	30 (5.4)	45 (16.1)	84 (30.4)	0.000
I have been mocked because of my ethnicity	479 (86.1)	61 (11.0)	16 (2.9)	35 (12.5)	42 (15.2)	0.354
I have been verbally threatened	394 (70.9)	124 (22.3)	38 (6.8)	56 (20.0)	106 (38.4)	0.000
Physical component	101 (18.2)	450 (80.9)	5 (0.9)	210 (75.0)	245 (88.8)	0.000
I have been physically hit	516 (92.8)	33 (5.9)	7 (1.3)	10 (3.6)	30 (10.9)	0.001
I have been exposed to unnecessary risks	378 (68.0)	156 (28.0)	22 (4.0)	70 (25.0)	108 (39.1)	0.000
I have been assigned excessive workloads	117 (21.1)	271 (48.7)	168 (30.2)	200 (71.4)	239 (86.6)	0.000
Academic component	76 (13.7)	445 (80.0)	35 (6.3)	223 (79.6)	257 (93.1)	0.000
I have been assigned tasks as punishment	220 (39.6)	255 (45.8)	81 (14.6)	147 (52.5)	189 (68.5)	0.000
I have been threatened with failing a course or rotation	246 (44.2)	210 (37.8)	100 (18.0)	109 (38.9)	201 (72.8)	0.000
I have experienced unfair competition	181 (32.6)	253 (45.5)	122 (21.9)	161 (57.5)	214 (77.5)	0.000
Others have taken credit for my work	218 (39.2)	255 (45.9)	83 (14.9)	131 (46.8)	207 (75.0)	0.000
Sexual component	279 (50.2)	274 (49.3)	3 (0.5)	113 (40.4)	164 (59.4)	0.000
I have been discriminated against because of my gender	461 (82.9)	70 (12.6)	25 (4.5)	40 (14.3)	55 (19.9)	0.077
I have been subjected to sexual verbal innuendos or obscene comments	357 (64.2)	154 (27.7)	45 (8.1)	75 (26.8)	124 (44.9)	0.000
I have been discriminated against because of my sexual orientation	520 (93.5)	28 (5.1)	8 (1.4)	13 (4.6)	23 (8.3)	0.077
I have received indecent propositions	425 (76.4)	103 (18.5)	28 (5.1)	39 (13.9)	92 (33.3)	0.000
I have been shown offensive sexual images	495 (89.0)	51 (9.2)	10 (1.8)	24 (8.6)	37 (13.4)	0.068
I have been shown offensive sexual body language	388 (69.8)	140 (25.1)	28 (5.1)	68 (24.3)	100 (36.2)	0.002
I have been touched without consent	479 (86.1)	61 (11.0)	16 (2.9)	25 (8.9)	52 (18.8)	0.001
I have been sexually blackmailed	519 (93.3)	30 (5.4)	7 (1.3)	10 (3.6)	27 (9.8)	0.003

^*P-value between study cycle and types of mistreatments

Significant differences in perceived psychological, physical, academic, and sexual mistreatment were observed by study cycle, with higher rates among clinical sciences students (p < 0.05). Psychological mistreatment was the most prevalent in basic sciences 89.3% (n = 250/280), as well as, in clinical sciences 97.8%, (n = 270/276). In addition, significant differences were identified in seven of eight psychological mistreatment items, all physical and academic mistreatment questions, and five of eight sexual mistreatment ones (Table 2).

Among all participants that reported perceiving mistreatment, 88.0% (n = 471/535) indicated that it occurred at faculty of medicine, while 56.8% (n = 304/535) at teaching hospitals environment, with significantly higher rates in clinical sciences students (p < 0.05) (Table 3).

Table 3. Differences in perpetrators of mistreatment by study cycle among medical students who perceived mistreatment at a public Ecuadorian university, 2024

Perpetrators of mistreatment	Frequency			Study cycle
	Never	Frequent	Recurrent	Basic sciences	Clinical sciences
	(0 times)	(1–5 times)	(≥ 6 times)	n = 263 (%)	n = 272 (%)	p*
Place
Hospital	231 (43.1)	224 (41.9)	80 (15.0)	61 (23.2)	243 (89.3)	0.000
Medical school	64 (12.0)	314 (58.7)	157 (29.3)	223 (84.8)	248 (91.2)	0.001
Perpetrators
Faculty physician	65 (12.1)	315 (58.9)	155 (29.0)	222 (84.4)	248 (91.2)	0.017
Non-faculty physician	299 (55.9)	194 (36.2)	42 (7.9)	67 (25.5)	169 (62.1)	0.000
Residents	361 (67.5)	140 (26.1)	34 (6.4)	23 (8.7)	151 (55.5)	0.000
Nursing staff	294 (55.0)	177 (33.0)	64 (12.0)	44 (16.7)	197 (72.4)	0.000
Obstetrician	463 (86.5)	63 (11.8)	9 (1.7)	14 (5.3)	58 (21.3)	0.000
Health technicians	436 (81.5)	85 (15.9)	14 (2.6)	40 (15.2)	59 (21.7)	0.054
Patients	297 (55.5)	197 (36.8)	41 (7.7)	56 (21.3)	182 (66.9)	0.000
Administrative staff	318 (59.5)	173 (32.3)	44 (8.2)	90 (34.2)	127 (46.7)	0.003
Institutional authorities	339 (63.3)	149 (27.9)	47 (8.8)	83 (31.6)	113 (41.5)	0.017
Medical students	253 (47.3)	232 (43.4)	50 (9.3)	135 (51.3)	147 (54.0)	0.530
Security personnel	362 (67.6)	149 (27.9)	24 (4.5)	60 (22.8)	113 (41.5)	0.000

^*P-value between study cycle and mistreatment perpetrators

Related to perpetrators of mistreatment, faculty physicians were identified as the most frequent one 87.9% (n = 470/535) by participants. Statistically significant differences were observed between the training cycles, with a higher prevalence of abuse by almost all perpetrators in the clinical science group, except health technicians and fellow medical students, where no significant differences were observed. (p < 0.05) (Table 3).

Regarding mistreatment consequences, 94.8% (n = 507/535) of affected students reported negative impacts, with personal effects being most prevalent, with a frequency of over 90%, followed by academic and social effects. The latter two being significantly more prevalent in clinical sciences students (p < 0.05) (Table 4).

Table 4. Differences in perceived mistreatment consequences by study cycle among medical students who perceived mistreatment at a public Ecuadorian university, 2024

Mistreatment effect	Frequency			Study cycle
	Never	Frequent	Recurrent	Basic sciences	Clinical sciences
	(0 times)	(1–5 times)	(≥ 6 times)	n = 263 (%)	n = 272 (%)	p*
Perceived effects	28 (5.2)	460 (86.0)	47 (8.8)	246 (93.5)	261 (96.0)	0.208
Personal domain	34 (6.4)	434 (81.1)	67 (12.5)	241 (91.6)	260 (95.6)	0.061
Stress	125 (23.4)	298 (55.7)	112 (20.9)	196 (74.5)	214 (78.7)	0.257
Distress	101 (18.9)	268 (50.1)	166 (31.0)	206 (78.3)	228 (83.8)	0.104
Insecurity	75 (14.0)	254 (47.5)	206 (38.5)	217 (82.5)	243 (89.3)	0.023
Fear	139 (26.0)	245 (45.8)	151 (28.2)	189 (71.9)	207 (76.1)	0.264
Depression	126 (23.6)	246 (46.0)	163 (30.5)	188 (71.5)	221 (81.3)	0.008
Cynicism	142 (26.5)	270 (50.5)	123 (23.0)	179 (68.1)	214 (78.7)	0.005
Negative effects on physical health	166 (31.0)	237 (44.3)	132 (24.7)	173 (65.8)	196 (72.1)	0.117
Negative effects on mental health	165 (30.8)	246 (46.0)	124 (23.2)	169 (64.3)	201 (73.9)	0.016
Suicidal ideation or attempts	338 (63.2)	134 (25.0)	63 (11.8)	77 (29.3)	120 (44.1)	0.000
Educational domain	86 (16.1)	379 (70.8)	70 (13.1)	211 (80.2)	238 (87.5)	0.022
Deficits in acquiring new skills/knowledge	145 (27.1)	277 (51.8)	113 (21.1)	184 (70.0)	206 (75.7)	0.133
Loss of enthusiasm and motivation for medical practice	112 (20.9)	284 (53.1)	139 (26.0)	197 (74.9)	226 (83.1)	0.020
Considering abandoning my studies	76 (14.2)	445 (83.2)	35 (6.5)	135 (51.3)	159 (58.5)	0.098
Social domain	128 (23.9)	374 (69.9)	33 (6.2)	185 (70.3)	222 (81.6)	0.002
Relationships breakdowns	198 (37.0)	254 (47.5)	83 (15.5)	150 (57.0)	187 (68.8)	0.005
Feelings of hostility or desires for revenge	280 (52.3)	209 (39.1)	46 (8.6)	100 (38.0)	155 (57.0)	0.000
Familial relational strain and emotional distancing	221 (41.3)	238 (44.5)	76 (14.2)	144 (54.8)	170 (62.5)	0.069

^*P-value between study cycle and effects of mistreatment

Among the most frequently reported effects were identified considering dropping out of school (89.7%), insecurity (86.0%) and distress (81.1%). Insecurity, depressive symptoms, cynical attitudes, mental health deterioration, suicidal ideation or attempts, loss enthusiasm and motivation for medical practice, relationship breakdowns and feelings of hostility or desires for revenge were reported more frequently among clinical sciences students, with statistically significant differences (p < 0.05) (Table 4).

Regarding underreporting of mistreatment, 91.4% (n = 489/535) of students who reported having experienced mistreatment did not notify the event to any formal authority. Basic sciences with 92.8% (n = 244/263) and clinical sciences students with 90.1% (n = 245/272). This omission was reported by 92.8% (n = 244/263) between basic sciences students and 90.1% (n = 245/272) in clinical sciences students.

The most cited reasons for non-reporting included fear of academic retaliation with 81.4% (n = 398/489) and perception that reporting could exacerbate problems or have no consequence 79.7% (n = 390/489). With all reasons statistically significant differences were found in all reasons for non-reporting, being significantly more common among clinical students (p < 0.05) (Table 5).

Table 5. Differences in mistreatment underreporting by study cycle among medical students who perceived mistreatment at a public Ecuadorian university, 2024

Underreporting reasons	Frequency			Study cycle
	Never	Frequent	Recurrent	Basic sciences	Clinical sciences
	(0 times)	(1–5 times)	(≥ 6 times)	n = 263 (%)	n = 272 (%)	p*
Notification (n = 535)	489 (91.4)	46 (9.4)		19 (7.2)	27 (9.9)	0.265
Causes of non-notification (n = 489)			n = 244 (%)	n = 245(%)
Not recognizing lived experience as mistreatment	151 (30.9)	247 (50.5)	91 (18.6)	156 (63.9)	182 (74.3)	0.013
Considering that mistreatment was not that important (n = 489)	120 (24.5)	234 (47.9)	135 (27.6)	168 (68.9)	201 (82)	0.001
Belief that reporting would lead to no consequences (n = 489)	99 (20.2)	140 (28.6)	250 (51.1)	182 (74.6)	208 (84.9)	0.005
Fear of retaliation for reporting mistreatment	99 (20.2)	146 (29.9)	244 (49.9)	181 (74.2)	209 (85.3)	0.002
I didn't know who or where to go to report the abuse	116 (23.7)	188 (38.4)	185 (37.8)	167 (68.4)	206 (84.1)	0.000
Thinking that reporting it would negatively impact my grades	91 (18.6)	147 (30.1)	251 (51.3)	185 (75.8)	213 (86.9)	0.002
Non-reporting due to cessation of abuse	243 (49.7)	181 (37.0)	65 (13.3)	109 (44.7)	137 (55.9)	0.013
Fear of non-confidential reporting processes	125 (25.6)	152 (31.1)	212 (43.4)	170 (69.7)	194 (79.2)	0.016
Not considering that the problem would be treated fairly	135 (27.6)	144 (29.4)	210 (42.9)	158 (64.8)	196 (80)	0.000
Shame	183 (37.4)	161 (32.9)	145 (29.7)	139 (57)	167 (68.2)	0.011
I was afraid of not being believed	161 (32.9)	164 (33.5)	164 (33.5)	147 (60.2)	181 (73.9)	0.001
I was afraid to report the abuse	162 (33.1)	151 (30.9)	176 (36.0)	150 (61.5)	177 (72.2)	0.011
Avoidance of mistreatment-related memories	186 (38.0)	168 (34.4)	135 (27.6)	133 (54.5)	170 (69.4)	0.001
I was concerned about potential negative career repercussions	139 (28.4)	142 (29.0)	208 (42.5)	158 (64.8)	192 (78.4)	0.001

^*P-value between study cycle and reasons for underreporting

Clinical sciences students had significantly higher risk of mistreatment exposition to all types: psychological, physical, academic and sexual. Related to gender were observed that female students had lower risk of physical mistreatment (OR: 0.60; IC 95%: 0.36–0,99) but higher risk of sexual mistreatment (OR: 1.77; 95% CI: 1.23–2.55) compared with males students (Table 6).

Table 6. Analysis of risk factors according to mistreatment type among medical students at a public Ecuadorian university, 2024

Variables	Mistreatment		Psychological mistreatment		Physical mistreatment		Academic mistreatment		Sexual mistreatment
	AOR (IC 95%)	p	AOR (IC 95%)	p	AOR (IC 95%)	p	AOR (IC 95%)	p	AOR (IC 95%)	p
Gender (Female)	1.05 (0.41–2.69)	0.915	1.24 (0.60–2.55)	0.562	0.60 (0.36–0.99)	0.044	1.02 (0.60–1.74)	0.932	1.77 (1.23–2.55)	0.002
Marital status (Single)	2.91 (0.33–25.73)	0.337	1.65 (0.19–14.29)	0.651	0.99 (0.21–4.76)	0.994	0.60 (0.07–4.9)	0.631	0.26 (0.07–1.01)	0.052
Ethnic self-identification (ethnic minority)	0.87 (0.24–3.18)	0.836	0.87 (0.31–2.41)	0.79	0.77 (0.38–1.53)	0.451	0.70 (0.34–1.47)	0.348	0.61 (0.32–1.14)	0.123
Study cycle (clinical sciences)	4.55 (1.46–14.19)	0.009	5.81 (2.33–14.50)	0.000	2.46 (1.52–3.98)	0.000	3.29 (1.86–5.82)	0.000	2.07 (1.44–2.97)	0.000
Enrollment type (Re-enrollment)	1.07 (0.30–3.84)	0.918	1.50 (0.50–4.47)	0.471	1.05 (0.53–2.07)	0.897	0.95 (0.46–1.96)	0.882	0.62 (0.34–1.12)	0.114

AOR Adjusted Odds Ratio, IC 95% Confidence Interval

Discussion

This study examined the perception, typology, perpetrators, and consequences of mistreatment among medical students, with particular attention to differences across stages of training. Although mistreatment was reported by a substantial proportion of students, only a subset recognized these experiences as such, suggesting normalization and adaptation processes that may obscure the true magnitude of the problem. Previous studies have widely documented the presence of mistreatment during medical training. Naif Fnais and colleagues in a systematic review and meta-analysis reported a global prevalence approximated 60% [10], however, have been reported variations between countries ranging from 48.7 to 84.5%, and percentages above 70% in countries such as United States [11, 12, 13, 14–15]. In Latin America, numerous studies reported prevalence rates are consistently higher, exceeding 90% in countries such as Brazil, Chile and Peru, with public institutions showing greater prevalence than private ones [2, 16, 17–18]. These results are consistent with the findings of the present study, reinforcing evidence that mistreatment in medical academic environments constitutes a systemic problem, and prevalence escalates progressively throughout medical training, peaking during final academic years and clinical internships, likely due to increased exposure to hierarchical environments and more pronounced power dynamics [3, 19, 20].

The low perception of mistreatment in spite of high occurrence, may be explained by several factors, including the internalization of these behaviors as part of formative process, systematic repetition of the phenomena over the time, and the fact that many events take place in clinical settings in front of patients, which increases the tolerance and resignation of students [15, 21]. An estimated 25% of those experiencing mistreatment fail to recognize it, perpetuating its invisibility and making it difficult to implement corrective measures [22, 23].

According to the type of mistreatment, psychological one was the most prevalent (93.5%), followed by academic (86.5%), physical (80.8%), and sexual (49.8%), with significantly higher rates in clinical sciences students. These findings align with regional and international reports, where verbal abuse, excessive academic pressure and emotional disqualification are the most common forms of mistreatment [17, 22, 24] High prevalence in clinical training phases likely reflects increased healthcare professional interactions and hierarchical structure of medical education, which tends to reinforce patterns of authority and subordination [17].

The settings where mistreatment occurred were mainly the medical school (88,0%) and teaching hospitals (56,8%), being more frequent in clinical science students. These findings are consistent with previous research documenting the presence of mistreatment in both classroom and clinical settings, varying according to interaction type and hierarchical level involved [2, 25]. Power dynamics and organizational structure in hospital settings can facilitate the perpetuation of these abusive behaviors, especially when there are no effective institutional mechanisms of prevention and punishment [17, 22].

Faculty physicians were the most frequent perpetrators (87.9%), followed by fellow medical students (52.7%). This pattern aligns with global studies reports, across diverse contexts including Thailand, South Africa, Nigeria and many countries of Latin America [3, 12, 15, 17, 22, 24, 26, 27]. Faculty physicians and healthcare professionals as authorities represent a critical figure in both perpetuating and preventing mistreatment. Likewise, the participation of other actors such as residents, nursing staff and patients has been documented, reflecting the multidimensional phenomena and the need for comprehensive intervention approaches [11, 15, 22, 24, 27].

In accordance with the effects, over 90% of affected students reported negative consequences, most frequently insecurity, anxiety, loss of enthusiasm, depression, and stress. These findings align with international studies documenting association between mistreatment and affections in mental health, substance use, academic performance deterioration, and in extreme cases, self-harm or suicidal ideation [12, 17, 19, 22, 24]. Beyond personal and academic repercussions, it has been evidenced that these experiences negatively impact future professional performance and the quality of care provided by future healthcare professionals [27].

Despite the high prevalence of mistreatment, 90.6% of students who perceived it did not report. Primarily due to fear of academic retaliation, as unfair grades (81.4%), and perception that complaining may not bring results or could exacerbate problems (79.8%). This non-reporting pattern aligns with global studies, which point to the existence of structural and institutional barriers that discourage reporting, such as the absence of confidential channels, institutional impunity, and the normalization of such behaviors in the medical environment [12, 17, 20, 23, 26, 28, 29]. This scenario reveals a worrying lack of confidence in reporting systems, which contributes to institutional tolerance of mistreatment and perpetuates its recurrence.

A 2022 multicenter American study found female medical students had 41% lower risk of physical mistreatment but 1.6 times higher risk of suffering some kind of sexual harassment on university environment compared to males [25]. These findings align with previous literature, identifying gender as a relevant determinant of mistreatment typology, with women and sexual minorities-including gays, lesbians and bisexual individuals- registering the highest rates of sexual mistreatment during medical training. Furthermore, it has been described that the highest levels of sexual mistreatment against women occur during the last semesters of medical school, particularly in the clinical internship, a stage characterized by increased exposure to hierarchical hospital environments [17, 30, 31]. Consistently, in the present study was observed that female participants experienced 40% reduced physical mistreatment risk but 1.7 times greater sexual harassment risk compared with males, this underscores the need to apply a gender approach in prevention strategies and support systems addressing mistreatment in educational and clinical environments.

In response to this global challenge, various institutions have initiated programs aimed at preventing mistreatment in medical education. A review published in JAMA identified only ten formally evaluated interventions, which included awareness campaigns, zero-tolerance policies, confidential reporting systems, and faculty training in communication and empathy [32]. While some strategies showed modest reductions in mistreatment prevalence, significant methodological and implementation limitations persist [33, 34]. Qualitative studies have highlighted the need for clear policies, accessible and reliable reporting processes, and an approach to medicine’s hierarchical culture through hidden curriculum transformation [34, 35].

The findings of this study highlight the urgent need for comprehensive, evidence-based institutional policies in Ecuadorian medical schools. These should focus on the prevention, early detection, and effective management of mistreatment, with an emphasis on human rights, gender equity, and mental health promotion. This is the first study to systematically characterize mistreatment among medical students at a public university in Ecuador, offering essential data to inform the development of locally relevant interventions.

Limitations

This study has some limitations that should be considered when interpreting the results. First, as a cross-sectional design, it cannot establish causal relationships between the analyzed variables. Additionally, the collected data relied on students' self-reported perceptions, which may be subject to memory bias, underreporting or social desirability bias. Furthermore, the research was conducted at a single public university in Ecuador, which may limit the generalizability of the findings to other institutions in the country or region. Finally, the study did not examine specific institutional context factors, such as the presence, accessibility and perceived efficacy of formal reporting systems, which may significantly influence both the occurrence and recognition of mistreatment.

Conclusions

Mistreatment in medical training is a highly prevalent problem, with special emphasis during clinical training, where students face increased exposure to hierarchical environments and power relations. This study confirms that attending physicians are the primary perpetrators, with psychological and academic mistreatment being the most common forms, followed by physical and sexual abuse. However, significant gender disparities were identified, highlighting a higher risk of sexual mistreatment in females. Underreporting of these events, due to fear of academic retaliation and lack of confidence in institutional reporting mechanisms, represents a critical barrier. These findings reinforce the imperative to develop comprehensive, gender-sensitive institutional strategies focused on prevention, detection, and effective management of mistreatment in medical education.

Acknowledgements

The authors would like to thank the teachers who distributed the survey to their students. They also thank Professor Alberto Narváez for his unconditional support and guidance throughout the development of this study.

Author contributions

Conceptualization and design: JPGG, KSR, LNAC Data collection and curation: JPGG, DJSC, IALM, JAGG, JEM, KAT Formal Analysis: JPGG, KSR, PRQ, JSPA Funding Acquisition: KSR Research: JPGG, KSR, LNAC, DJSC, IALM, JAGG, JEM Methodology: JPGG, KSR, DJSC, GERM, PRQ Project Administration: JPGG, KSR, GERM, PRQ Resources: JPGG, KSR, JSPA Software: JPGG, JSPA Supervision: JPGG, KSR, IALM Validation: JPGG, KSR, DJSC, KAT Visualization: JPGG, KSR, DJSC, KAT, JEM Writing—Original Draft: JPGG, KSR, DJSC, LNAC, KAT, IALM, JAGG, JEM, GERM, PRQ, JSPA Writing—Review and Editing: JPGG, KSR, DJSC, LNAC, KAT, IALM, JAGG, JEM, GERM, PRQ, JSPA.

Funding

Authors declare having received financial support for the publication of this article. The Pontificia Universidad Católica del Ecuador funded the publication costs related to this manuscript.

Data availability

The datasets generated and/or analyzed during the current study are not publicly available due to confidentiality concerns involving sensitive participant information, but they are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

The study was reviewed and approved by the Research Ethics Committee on Human Subjects at Hospital General San Francisco de Quito (CEISH-HGSF); Approval Code: HREC-HGSF-2024–019. All participants provided digital informed consent before questionnaire access and were informed that all survey data and interview recordings and data collected would be kept private, ensuring adherence to Helsinki Declaration principles (autonomy, justice, beneficence) and current national regulations.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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